obesity in portugal pedro moreira
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Portugal: overweight and obesity in children andadolescents
Introduction
1. No ongoing national surveillance system2. Prevalence of Overweight and Obesity
- 7-9-year-old from Portuguese Continent (Study 1)- 6-10-year-old from Madeira (Study 2)- 6-16-year-old from Azores (Studies 3 and 4)- 13-14-year-old from Porto (Study 5)
3. Determinants of overweight/obesity 4. Local applications
Studies 3,4
Study 1 - Continental area
Study 2
Study 5
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Methods - Study 1 (Continental area)
• Setting– School-based
• Convenience sample of 7-9-y-old children– Children attending public schools– Protocol approved by the Portuguese Institution of the Ministry of
Education (Direcção Regional de Educação)– Written explanation of the purpose and design of the study– Written informed consent from parents/legal guardian– Schools were randomly selected in the districts and from each of them
the participating children were selected using stratified randomization for age
– Included: n = 4511 (2274 girls; 50.4% girls)– Not included: n = 336 (other countries; diseases; < 6 years)– Response rate: 70.6%.
Data collection: Study 1 (Continental area)
• Data collection: October 2002 to June 2003• Trained technicians performed anthropometric measurements
using internationally standardized procedures– Height was measured using a stadiometer (precision of 1 mm)– Weight was measured using an electronic scale (precision of
100 g)• Children's parents: self-administered questionnaire
– Family background (children’s birthweight, order of birth, breastfeeding, smoking during pregnancy, physical activity, parental BMI, parental education)
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Data collection: Study 1 (Continental area)
• Children's dietary intake: 24-h dietary recall• 2 weeks course for training and standardization of
fieldworkers (nutritionists, senior students from sports and physical education and anthropology faculties)
• Overweight and obesity criteria– Cole et al. (2000)
Results – Study 1 (Continental area)
Criteria: Cole, 2000 Am J Hum Biol 2004;16:670-8
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1970
1992
2002
Am J Hum Biol 2004;16:670-8
Height and weight in 1970, 1992, and in Study 1
1970
1992
2002
1970
1992
2002
Am J Hum Biol 2004;16:670-8
5
Methods – Madeira (Study 2)
• Setting– School-based
• Convenience sample of 6-10-y-old children– Children attending public and private schools– Classes from schools were randomly selected in Madeira
• 128 classes, 1-4th grades• n = 2541
– Informed consent from parents– Response rate: 94.7% (n = 2407)– Not included: n = 23 (diseases that affect normal growth)– Final sample: n = 2384 (1126 girls; 47.2%)
Sousa et al.. Public Health Nutr 2006;9(7A):109
Data collection: Madeira (Study 2)
• Data collection: May 2004 to May 2005• Trained technician performed anthropometric
measurements using internationally standardized procedures– Height was measured using a stadiometer
(precision of 1 mm)– Weight was measured using an electronic scale
(precision of 100 g)
Sousa et al.. Public Health Nutr 2006;9(7A):109
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BMI for age in 6- to 10-years-old children of Madeira (Study 2), n = 2384
Classification criteria: CDC
Sousa et al.. Public Health Nutr 2006;9(7A):109
14.417.3
≥ percentile 95
6-10
Age (y)
17.714.1
≥ percentile 85 and< percentile 95
FemaleMale
Gender
32.131.4
Total (%)
Methods – Azores study 3
• Setting– School-based
• Sample of 6-10-y-old children– Schools were randomly selected in all islands and from
each of them the participating children were selected using stratified randomization in order to assure a number of subjects = 25% of all local students
– n = 3742
Maia et al., 2002
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11.68.2
241281
FemaleMale
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TOTAL
9
8
7
6
Age (y)
10.911.9
460429
FemaleMale
13.011.2
269286
FemaleMale
13.713.0
431453
Female Male
11.912.5
428464
FemaleMale
12.211.7
18291913
FemaleMale
Obese (%)nGender
Maia et al, 2002
Assessment of obesity in children of Azores (study 3) n = 3742
Criteria: Cole, 2000
Methods – Azores study 4
• Setting– School-based
• Sample of 6-19-y-old children and adolescents– Children attending public schools– Cohort study– Schools were randomly selected in 4 islands that represent
80% of total students from Azores• n=1159• 4 coortes (each ≈ n = 250): 6-10 y; 10-13 y; 13-16 y; and
16-19 y
Maia et al, 2006
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24.2
27.8
26.9
Overweight (%)
13-16
10-13
6-10
Age (y)
10.0130
9.0133
2.291
Obese (%)n
Assessment of obesity in girls ofAzores study 4 (n = 354)
Criteria: Cole, 2000Maia et al, 2006
Methods: Adolescents-Porto (study 5 - EpiTeen)
• Setting– School-based
• Design– Cohort study
• Sample of 13-14-y-old adolescents– Approved by the Ethics Committee of the São João University Hospital – Protocol approved by the Portuguese Institution of the Ministry of
Education Adolescents attending public (n = 27) and private (n = 24) schools (teaching from the 5th to the 9th grade); allowed to reach eligible students:
• All public schools • 19 (79%) private schools
– Adolescents born in 1990 were expected to be enrolled at any of the 51 schools
– Written explanation of the purpose and design of the study– Written informed consent both from parents/legal guardian and
adolescentsRamos E, 2006
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Data collection: Adolescents-Porto (study 5)
• Data collection: October 2003 to June 2004• Trained technician performed anthropometric
measurements using internationally standardized procedures– Height was measured using a stadiometer
(precision of 1 mm)– Weight was measured using an digital scale with a
precision of 100 g
Ramos E, 2006
Adolescents-Porto (study 5)n = 2040; adolescents born in 1990; age = 13-14 y
Overweight + obeseObeseOverweight
27.4%
24.5%
6.6%
5.7%
20.8%
18.8%
Males (n = 987)
Females (n = 1053)
Classification criteria: Cole, 2000
Ramos E, 2006
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Association between overweight /obesity and other variables
Study 1 (7-9 y children, n = 4511; Continental area)
Acta Pædiatrica 2005;94:1550–7
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Acta Pædiatrica 2005;94:1550–7
Study 1 (Continental area)
Eur J Clin Nutr 2005;59:861-867
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0,00 10,00 20,00 30,00 40,00Calcium-to-protein (mg/g)
10,00
15,00
20,00
25,00
30,00
35,00
BM
I (kg
/m2)
y = -0.052x +18.550
0,00 5,00 10,00 15,00 20,00 25,00 30,00Calcium-to-protein (mg/g)
10,00
15,00
20,00
25,00
30,00
BM
I (kg
(m2)
y = -0.012x + 17.891
Girls Boys
Study 1 (Continental area)
Eur J Clin Nutr 2005;59:861-867
* Adjusted for gender, age, birthweight, order of birth, breastfeeding, smoking during pregnancy, physical activity, parental BMI, parental education, calcium to protein ratio, and energy intake.
0.038 1.01 - 1.61 1.27 < 0.001 1.27 - 1.841.53≥ 16.0 kg
0.90 - 1.60 1.20 1.04 - 1.651.3113.6-15.9 kg
0.91 - 1.37 1.12 0.98 - 1.361.159-13.5 kg
(reference) 1.00 (reference) 1.00 < 9 kg
p trend95% CI OR p trend95% CI OR
Adjusted*CrudeWeight gain during pregnancy
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Study 1 (Continental area)
[Health MinistryHealth General Directorate]
National programme in “design” phase
[National programme against obesity]
Application: actions been taken
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[National plan against obesity wants better meals in schools]
Publico, 07.02.2006
Collaboration with City Hall in formulating guidelines for school meals in Primary
schools of Porto
Nutritional adequacy of meals from Primary schools of Porto
Rev Alim Hum 2003;9:83-90[schools exagerate in fried and high sugar foods]
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Major objectives in thePortuguese National Plan Against Obesity
• …• Promote in the schools the availability of energetic
balanced meals• Create technical guidelines to identify children with
risk factors and to approach obesity in school environment
• Create an observatory to collect information about obesity prevalence, incidence and comorbidities
• …
[healthy eating promotion]
[Health MinistryHealth General Directorate]
Nutrition education as a aim in schools
[school health]
[nutrition education]
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Regulate food consumption in school cafeterias
• Limit high energy dense micronutrient poor foods– Cookies– Cakes– Chocolates
• Remove – Fried foods– Mayonnaise– Sugars sweetened soft drinks– Candies– Hamburgers, hot dogs and pizzas
[WHO – Health promotion and lifestyles]
[National Programme of Health in the Schools]
[2015, 50% of children in kinder gardens and 95%of children in the schools should integrate “Health Promotion Schools”]
[Health MinistryHealth General Directorate]
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[Raise awareness to childhood obesity]
[Health MinistryHealth General Directorate]
14.10.2006Porto, Coimbra, Braga, Aveiro,
Castelo Branco
[Raise awareness to childhood obesity] General –Director of HealthDr. F George
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[Decrease the marketing of foods to children]
[Marketing regulation tofight against childhood obesity]
1st step:Approved in12.10.2006
Approved in12.10.2006
Comissão Parlamentar de Saúde[Parliament Commission of Health]
PlenariumVoted
Conclusions
• High prevalence of overweight/obesity in Portuguese children
• Need for standardized childhood obesity surveillance and prevention